This document discusses paediatric HIV, including: 1) Over 2 million children under 15 were living with HIV by 2006, most acquiring it vertically from their mothers. Prevention of mother-to-child transmission focuses on antiretroviral prophylaxis and treatment. 2) HIV infected children can receive routine immunizations which are generally safe and effective, though antibody response may be impaired. Live attenuated vaccines require additional precautions for immunosuppressed children. 3) Clinical monitoring of perinatally exposed infants includes growth, development, and screening for opportunistic infections. HIV testing is done via PCR and serology. Antiretroviral therapy aims to suppress viral load and improve CD4 counts.

1. Paediatric’s HIV
Koh Kian Chuan

2. Virus classification
Group: Group VI (ssRNA-RT)
Order: Unassigned
Family: Retroviridae
Subfamily: Orthoretrovirinae
Genus: Lentivirus
Species
•Human immunodeficiency virus 1
•Human immunodeficiency virus 2

3. HIV

4. pathophysiology

5. Introduction
• By the end of 2006, estimated 2.3million children <15 years old
living with HIV with an estimated half a million new infections
occurring in children
• Children < age 12 years old constituted 1.5% of total reported
cases for 2006, those aged 13-19 years 1% and those aged 20-29
years 2.7%
• Vast majority of paediatric HIV infections are acquired vertically
• In developed countries, number of children of HIV positive
mothers newly infected with HIV has dramatically decreased
with a perinatal transmision rate of <1% a result of antiretroviral
(ARV) prophylaxis and the use of highly active antiretroviral
therapy (HAART) for pregnant HIV infected mother

6. Prevention of mother to child
transmission
• 3 components of treatment or prophylaxis
(antepartum, intrapartum and neonatal)
• Longer courses of ARV prophylaxis
• Therapy beginning earlier in pregnancy
• Combination regimens

7. Factors associated with higher
transmission rate
• Maternal
– Low CD4 counts
– High viral load
– Advanced disease
– Seroconversion during pregnancy
• Fetal
– Premature delivery
• Delivery and procedures
– Invasive procedures eg episiotomy
– Fetal blood sampling or amniocentesis
– Vaginal delivery
– Rupture of membrane >4 hrs
– chorioamnionitis

10. Investigation at birth
• FBC
• HbsAg, Hepatitis C, Toxoplasmosis, CMV, VDRL
serology
• LFT, RFT
• HIV DNA PCR

11. • Feeding
– not to breastfeed
– Against mixed feeding
• Immunization
– All infants born to HIV infected mothers should
receive routine childhood immunisation at the
usual recommended age

12. • BCG
– Administered to HIV infected infants in the first month
of life is associated with low rates of complications
– Complications: lymphadenitis
disseminated infection
IRIS (immune reconstitution
inflammatory syndrome)
– Very little data on effectiveness of BCG in HIV infected
children
• Polio
– OPV (live attenuated vaccine)--Rare complication:
vaccine –associated paralytic poliomyelitis (VAPP)

13. • MMR
– Live attenuated vaccine
– Risk of adverse reaction following vaccination was no
different HIV infected and uninfected children
– Studies on Immunogenicity of MMR vaccine in HIV
infected children –noted impairment of Ab response
with only half developing protective Ab level
• Hepatitis B
– Recombinant vaccine
– No significant adverse event
– Immunogenicity: poorer response rate in HIV infected
children with only 25-50% developing protective
antibodies

14. • Hib
– Conjugated polysaccharide vaccine
– Safe and immunogenic
• DTP
– Safe and immunogenic
• Pneumococcal vaccine
– Children infected with HIV have a markedly increased risk
of pneumococcal infection
– Both PPV and PCV are safe
– ~ 65-100% of HIV infected children developed protective
Ab after PCV vaccination
– ART and PPV –independent protective effect against
pneumoccocal disease regardless of CD4 count

15. • Varicella vaccine
–Safe and good immunogenicity
–2 doses with 2 months interval
–omit in those with severe
immunosuppression (CD4<15%)
Despite vaccination, remember long term protection may not
be achieved in severe immunosuppression ie, they may still be
at risk of acquiring infections!

16. • Precautions recommended for live-attenuated
vaccines:
– BCG should not be given in symptomatic HIV
infected infants or children (WHO stage 2,3,4) as
they are at higher risk of developing disseminated
disease
– OPV should be replaced by injectable Inactivated
Polio Vaccine
– MMR should be given as per schedule except to
those who have severe immunosuppression
(CD4<15%)

18. Common Clinical features
• Persistent lymphadenopathy
• Hepatosplenomegaly
• Failure to thrive
• Developmental delay
• Recurrent infections (respiratory, skin,
gastrointestinal)

19. Clinical and Laboratory monitoring of
perinatally exposed infant
• Clinical monitoring
– Physical growth
– Developmental milestones
– Early detection of opportunistic infections
– Review of immunization
– Adverse effects of drug therapy

20. Virologic and serologic monitoring
• HIV PCR DNA is done at 14-21 days, at 1-2
months of age, and at 4-6 months of age
• Serologic testing after 12 months of age

22. Primary PCP prophylaxis
• Recommended for infants with indeterminate HIV infection status starting
4-6 weeks of age till they are determined to be HIV-uninfected or
presumptively uninfected
• Primary TMP-SMX prophylaxis should be continued until at least 1 year of
age for HIV-infected infants and then re-evaluated
• Further use of prophylaxis is guided by clinical staging and CD4%

23. Management of HIV infected infants,
children and adolescents
• Monitoring of disease progression
– Clinical
– Immunologic- CD4 count and %
– Virologic – plasma viral load assay

26. Antiretroviral therapy
• At least 3 drugs
• Monotherapy and dual ART- found Not to provide
sustained viral suppression, increased risk of
resistance
• Benefits of HAART:
– Reduce mortality by 67-80%
– Halt progression to AIDS by 50%
– Reduce hospitalization rate by 68-80%
– Reduce incidence of opportunistic infections by 62-
93%

27. When to initiate therapy

30. Monitoring of HIV infected child on
treatment
• Clinical: adherence, drug adverse effects, and
improvements in height, weight and development
• Virologic : plasma viral load monitored at week 8,
week 12 and every 4-6 months thereafter or
whenever there is significant decline in CD4 + T cells
• Immunologic: CD4 should be monitored 3-4 monthly
– CD4% expected to increase ranging from 5-10% at 6
months with continued rise through 1st 2-3 years of
HAART
– Patients with discordant responses should be referred to
paediatric infectious diseases specialist

31. Immune reconstitution inflammatory
syndrome
• Characterized by paradoxical clinical worsening of a
known condition or the appearance of a new
condition after initiating ART and results from
restored immunity to infectious and non-infectious
agents
• Proposed definition:
– Decrease in HIV-1 RNA level from baseline
– increase in CD4+ cells from baseline
– Clinical symptoms consistent with inflammatory process
– Clinical courses not consistent with
• Expected course of previously diagnosed OI
• Expected course of newly diagnosed OI
• Drug toxicity

32. Treatment failure

35. Follow up
• Every 3-4 months, if just commencing or
switching HAART then every 2 weeks
• Ask about medications
• Side effects: vomiting, abdominal pain, jaundice
• Examine: growth, HC, pallor, jaundice, oral thrush
• FBC, CD4, viral load every 3-4 months
• RFT,LFT,CA/PO4 (amylase if on didanosine)
6monthly
• Referral to social welfare

36. • Thank you